Provider Demographics
NPI:1609692052
Name:BEACH, MARISSA JADE
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:JADE
Last Name:BEACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 WEDGEWOOD DR UNIT 6250
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44312-2479
Mailing Address - Country:US
Mailing Address - Phone:888-238-1818
Mailing Address - Fax:855-915-1521
Practice Address - Street 1:1603 CAPITOL AVE STE 413C1005
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4569
Practice Address - Country:US
Practice Address - Phone:307-364-3181
Practice Address - Fax:855-915-1521
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYRBT-24-396396106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician